From The Floor

The Nursing Chain of Command

A tragic case that could have been prevented if the triage nurse had turned to her nursing superiors for guidance.

Many of my readers know of the tragic death of Edith Isabel Rodriguez at King-Harbor (the former King-Drew Medical Center) on May 9, 2007. Just in case there are some who are unaware of the events on that fateful day, let me provide the following brief synopsis (as reported in the press and to the Los Angeles County Board of Supervisors).

Sometime during the first week of May, Rodriguez presented multiple times at the Emergency Room of King-Harbor Hospital, complaining of abdominal pain. It has been reported that on at least three occasions she was examined, provided pain medication, and then released. A mere six hours after her last visit she returned to the King-Harbor ER complaining again of severe abdominal pain. The triage nurse on duty at the time informed her that there was nothing more that could be done. As she writhed in pain in the hallway, her boyfriend went around frantically trying to get help, going so far as to call 911. Since she had become a disturbance, hospital police were called. They ran a background check, found that the patient had an outstanding warrant, and she was arrested! As she was wheeled out to the waiting patrol car, she became unresponsive, and was taken back to the ER where she died. An autopsy later discovered that she died of a perforated bowel. It was determined that if she had received treatment for this condition within the 24 hours prior to her death, there would have, in all likelihood, been a different outcome.

Fast forward to nearly a month later, and we find King-Harbor once again threatened with immediate jeopardy. The triage nurse on duty that evening resigned and has been reported to the California Board of Registered Nursing, along with several other nurses. One wonders, what could have gone so terribly wrong?

One possible scenario is that the triage nurse—who informed the patient that she had been seen six hours earlier and there was nothing more that could be done—could have turned to her superiors for guidance, advice, or to move the patient’s request up the chain of command. The nurse could have requested that the ER physician examine or reexamine the patient. In short, the nurse could have advocated more strongly for her patient.

Chain of Command = The Line of Authority

Every hospital, indeed, nearly every organization, has a chain of command. In most cases, this chain of command is delineated with a chart, often referred to as an organizational chart. The chain of command in its simplest definition is the line of authority and responsibility along which orders are passed within the nursing department, the hospital, and between different units. Nurses who ignore the chain of command may lose their jobs, and in some cases their licenses. My readers may remember an earlier article where I told of a nurse who failed to ensure that a patient received a much-needed transfusion. She paged the physician numerous times, who failed to respond, and in the end the patient died. The doctor received what amounted to a slap on the wrist, while the nurse lost her license for her failure to advocate for her patient.

There might be some who think that this punishment was overly harsh, however her failure to exhaust all remedies to get the order to perform the transfusion is what caused the Board of Registered Nursing to conclude that her failure to advocate for her patient was a key, if not the only, factor in the patient’s death.

If she had employed the chain of command she would in all likelihood, not have been held culpable. She failed to call and seek help from the head nurse or the charge nurse who were both in the position to advance her request. If she had contacted them and informed them of the situation then they would have been in the position to use their skills, position, and power to get the appropriate care for the patient.

Four Steps to Take

A nurse who uses the chain of command correctly protects the nurse, the patient, and ultimately, the hospital. The following steps will assure that the nurse is exercising all her patient advocacy muscles: • first, call on your head nurse or charge nurse, who can use their position to accelerate a response or get the necessary authorization. Keep in mind that different hospitals have slight variances on the nursing chain of command. • second, should this fail or if for some reason there is no head nurse or charge nurse available look to the Unit or Department Director of Nursing (DON). Typically DONs hold a 9 to 5 position, yet they can be asked to intervene at any time should the need arise. • third, if your scenario involves a physician and a patient is in jeopardy, know and use your chain of command. Remember that the Chief Nursing Officer (CNO) is your top advocate. In the organizational structure, the CNO is usually directly beneath the hospital administrator, and therefore, has a great deal of authority to assist in finding a positive solution to the problem. If the CNO is not responsive, then the next step is to contact the medical director or the hospital administrator or CEO depending on the issue. • fourth, always remember to document. If you are having trouble getting the appropriate authorization to administer medication or perform a procedure, be sure to notate this in the chart. If necessary and appropriate, you can also complete an incident report as defined by your hospital’s policies and procedures.

Asking for help is not a sign of weakness. Far too often nurses think that asking for such assistance makes them appear to be less competent. The chain of command can truly help a nurse solve a difficult situation, and it can also help protect a nurse’s license in case of a negative outcome. How well the nurses follow the chain of command can also serve as an indicator of the overall state of nursing in a particular hospital.

There is, of course, a possible downside to using the chain of command, which can occur where there are weak, insecure, poorly trained or bad managers. When a nurse seeks help through the chain of command and encounters resistance, apathy, or even incompetence, then he or she needs to document the steps taken to advocate for the patient. The nurse should also rely on the hospital’s policy and procedures regarding appropriate reporting protocols.

We may never truly discover why an experienced triage nurse or the other hospital employees seemed to ignore the cries of a patient in pain. If they felt helpless to offer assistance, did any of them seek out the next person in their chain of command? Doing this is not easy, as it requires effort and commitment. However nurses who are in precarious situations should never overlook the power of the chain of command and the positive results that can result from its implementation.

Geneviève M. Clavreul, RN, PhD, is a healthcare management consultant and a former Director of Nursing.